For youth ice hockey players, participating in a league that allows body checking increases the risk of injury and concussion, Canadian researchers found.

Action Points

Explain to interested patients that this study showed that the hockey league in which body checking was allowed had higher rates of injury and concussion and that, in that league, body checking was the predominant mechanism of injury.

For youth ice hockey players, participating in a league that allows body checking increases the risk of injury and concussion, Canadian researchers found.

The rates of all injuries, severe injuries, concussion, and severe concussion were all more than threefold higher in a Pee Wee hockey league (ages 11 and 12) that allowed body checking compared with one that didn't, according to Carolyn Emery, PhD, of the University of Calgary's Sport Medicine Center in Alberta, and colleagues.

"The public health implications associated with injury in Pee Wee hockey in which body checking is permitted are significant," the researchers wrote in the June 9 issue of the Journal of the American Medical Association.

Future studies will evaluate players in the next age group, when body checking is allowed in both leagues, and one cohort will have two years of body checking experience already.

"This research can inform the development and rigorous evaluation of prevention strategies to reduce the risk of injury in this population of youth ice hockey participants," Emery and her colleagues wrote.

Youth ice hockey is popular in Canada, with more than 550,000 young players registered with Hockey Canada.

Previous studies have shown body checking to be the primary mechanism of injury among youth players, accounting for 45% to 86% of all injuries.

In both the U.S. and Canada, the youngest age at which body checking is allowed is 11. In Quebec, however, it is not allowed until 13.

Emery and her colleagues compared the risk of injury between two Pee Wee ice hockey leagues, one in Alberta that allows body checking and one in Quebec that does not.

The study included 1,108 players from Alberta and 1,046 from Quebec. They were prospectively followed during the 2007-2008 season.

All teams were required to have a designated physiotherapist, athletic therapist, or senior therapy student.

Overall, there were 241 injuries, including 78 concussions, in Alberta during 85,077 exposure-hours, compared with 91 injuries, including 23 concussions, in Quebec during 82,099 exposure-hours.

The proportion of players who had two or more independent game injuries was 2.17% in Alberta and 0.38% in Quebec.

The incidence rate ratios comparing rates of game-related injuries in Alberta versus Quebec were as follows:

3.26 (95% CI 2.31 to 4.60) for all injuries

3.30 (95% CI 1.77 to 6.17) for severe injuries resulting in more than a week of lost time

3.88 (95% CI 1.91 to 7.89) for concussions

3.61 (95% CI 1.16 to 11.23) for severe concussions resulting in more than 10 days of lost time

Eliminating body checking would be expected to result in an absolute reduction -- per 1,000 player-hours -- of 2.84 injuries, 0.72 severe injuries, 1.08 concussions, and 0.20 severe concussions, according to the researchers.

Previous injury and concussion were associated with greater risks of injury and concussion, respectively.

Small player size and higher levels of play were both associated with greater risks of all injuries.

Players who indicated a greater preference for body checking at baseline had an elevated risk of severe injuries and severe concussions.

In Alberta, body checking was by far the most frequent mechanism of injury compared with other intentional player contact, incidental contact, and contact with the puck, boards, or net (2.72 per 1,000 player-hours versus 0.24 to 0.46).

In Quebec, incidental contact led the way compared with the other mechanisms (0.49 per 1,000 player-hours versus 0.20 to 0.24).

The injury rate attributed to other intentional contact, including elbowing, slashing, and tripping, was twice as high in Alberta as in Quebec, "suggesting a more aggressive style of play in which body checking is permitted," the researchers wrote.

They listed some limitations of the study, including the greater rate of dropout among teams in Quebec, the possible underestimation of minor injuries, the fact that not all players determined by the team therapist to have suffered a concussion followed up with a physician, some missing data, and the potential for misclassification of self-reported data.

The study was funded by the Canadian Institutes of Health Research and the Max Bell Foundation. It also received support from Hockey Calgary, Hockey Edmonton, Hockey Quebec, Hockey Alberta, Hockey Canada, and the Quebec Ministry of Education, Leisure, and Sport. Emery is supported by a Population Health Investigator Award from the Alberta Heritage Foundation, a New Investigator Award from the CIHR, and a Professorship in Pediatric Rehabilitation in the Faculty of Medicine, University of Calgary (Alberta Children's Hospital Foundation). One of her co-authors holds the Alberta Children's Hospital Foundation Professorship in Child Health and Wellness, funded through the support of an anonymous donor and the Canadian National Railway Company, as well as the Alberta Heritage Foundation for Medical Research Population Health Investigator and CIHR New Investigator Awards. One of the other authors is supported by the Senior Clinician Scientist program of the Fonds de la Recherche en Santé du Quebec.

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